Sulprex

• Chronic Obstructive Pulmonary Disease (COPD):
  For maintenance treatment and relief of bronchospasm in patients with moderate to severe COPD.
• Asthma:
  Adjunctive therapy for bronchospasm relief in acute exacerbations and chronic management when monotherapy is insufficient.
• Acute Bronchospasm:
  Treatment of reversible bronchospasm in obstructive airway diseases.
• Off-label Uses:
• Bronchospasm associated with bronchitis or emphysema.
• Prevention of exercise-induced bronchospasm when other treatments are inadequate.

• Adults and Adolescents (≥12 years):
• Metered-Dose Inhaler (MDI):
  Typically, 1 inhalation containing 100 mcg salbutamol and 20 mcg ipratropium, 3 to 4 times daily as needed.
• Nebulizer Solution:
  2.5 mg salbutamol plus 0.5 mg ipratropium nebulized every 6 to 8 hours, depending on clinical response.
• Children (6–11 years):
• Use with caution; dosing individualized, commonly nebulized salbutamol 0.15 mg/kg with ipratropium 20 mcg per dose.
• Elderly:
• No dose adjustment required; monitor for side effects.
• Renal and Hepatic Impairment:
• No specific dose adjustment necessary; caution advised.
• Administration Notes:
• Use of a spacer device with MDI is recommended for optimal delivery.
• Patients should be trained in proper inhaler technique.
• Duration depends on clinical need; may be used for long-term maintenance or acute relief.

Salbutamol selectively stimulates β2-adrenergic receptors on bronchial smooth muscle, increasing intracellular cyclic AMP and causing muscle relaxation, leading to bronchodilation. Ipratropium acts as a competitive antagonist at muscarinic M3 receptors in the airways, inhibiting acetylcholine-induced bronchoconstriction. The combination provides additive bronchodilatory effects by targeting both adrenergic and cholinergic pathways, enhancing airflow and symptom control in obstructive airway diseases.

• Salbutamol:
• Rapid absorption after inhalation; peak plasma levels within 5–15 minutes.
• Oral bioavailability approximately 50%.
• Metabolized in the liver mainly by sulfation.
• Excreted primarily in urine as metabolites and unchanged drug.
• Half-life: approximately 4 to 6 hours.
• Ipratropium:
• Poor systemic absorption after inhalation (<7% bioavailability).
• Minimal metabolism; excreted mainly unchanged in urine and feces.
• Half-life: about 1.6 hours.

• Pregnancy:
  Both salbutamol and ipratropium are classified as FDA Pregnancy Category C. Animal studies have indicated potential risks at high doses; human data are limited. Use only if clearly needed and after assessing risk-benefit ratio.
• Lactation:
  Both drugs are excreted in breast milk in small quantities. Use with caution during breastfeeding; monitor infants for adverse reactions.

• Primary Therapeutic Class:
  Combination bronchodilator.
• Subclass:
• Salbutamol: Short-acting β2-adrenergic receptor agonist (SABA).
• Ipratropium: Short-acting muscarinic antagonist (SAMA).

• Hypersensitivity to salbutamol, ipratropium, atropine, or formulation excipients.
• Known allergy to peanuts or soya lecithin (in some inhaler formulations).
• Use with caution or contraindicated in narrow-angle glaucoma and urinary retention secondary to prostatic hypertrophy.

• Cardiovascular Effects:
  May cause tachycardia, palpitations, or arrhythmias; use cautiously in patients with cardiovascular disease.
• Paradoxical Bronchospasm:
  Rare but serious; discontinue drug immediately if this occurs.
• Anticholinergic Effects:
  Possible dry mouth, urinary retention, or worsening of glaucoma symptoms.
• High-Risk Groups:
  Use with caution in elderly patients and those with glaucoma or prostatic hypertrophy.
• Monitoring:
  Monitor respiratory function and for anticholinergic adverse effects during treatment.

• Common:
• Tremor
• Headache
• Dry mouth
• Nervousness
• Palpitations
• Throat irritation or cough
• Serious/Rare:
• Paradoxical bronchospasm
• Worsening of narrow-angle glaucoma
• Urinary retention
• Allergic reactions including rash and angioedema
• Onset:
  Side effects usually occur shortly after administration.

• Beta-Blockers:
  May antagonize bronchodilatory effect of salbutamol.
• Other Anticholinergic Agents:
  Additive anticholinergic side effects with ipratropium.
• MAO Inhibitors and Tricyclic Antidepressants:
  May enhance cardiovascular effects of salbutamol.
• Sympathomimetic Drugs:
  May increase risk of cardiovascular side effects.
• Food and Alcohol:
  No significant interactions reported; alcohol may enhance CNS effects.

• GOLD guidelines recommend combined short-acting β2 agonist and anticholinergic therapy for symptom relief in COPD.
• No major recent changes in approved indications or dosing regimens.
• Emphasis on proper inhaler technique and adherence for optimal outcomes.

• Store at 20°C to 25°C (68°F to 77°F).
• Protect from moisture, heat, and direct sunlight.
• Keep inhalers and nebulizer solutions tightly closed when not in use.
• Do not freeze.
• Keep out of reach of children.